24DSCFH01-DSM Gut Health

1
If you do not qualify, do we have your permission to retain your contact information for future studies? (If you do not qualify and you do not consent, your information will be deleted/destroyed at the end of the recruitment process)
YESNO
2
Name
First Name
Last Name
3
Email
example@example.com
4
Phone Number
Please enter a valid phone number.
5
Postal Code
6
What was your assigned sex at birth?
Male
Female
7
Are you presently pregnant, planning to become pregnant or presently breastfeeding?
YESNO
8
Which form of birth control are you using?
I am no longer able to get pregnant (e.g., menopause (over 12 months), hysterectomy, bilateral oophorectomy, bilateral tubal ligation, complete endometrial ablation)
Hormone Contraceptives
Double barrier Method
Intrauterine Device
Non-heterosexual Lifestyle
Vasectomy of Partner (at least 6 months prior)
Abstinence
9
Please Enter Your Date of Birth
Date
Year
Month
Day
10
What is your current height?
Height Number
Please Select
Please Select
CM
INCHES
Height Metric
11
What is your current weight?
Weight Number
Please Select
Please Select
KG
LBS
Weight Metric
12
Have you gained or loss more then 5% of your body weight in the last 3 months? Has your weight been stable over the last 90 days.
YESNO
13
To help us better understand the diversity of our participants and ensure we are providing inclusive and equitable services, could you please let us know your racial or ethnic background? This information will be kept confidential and used only for demographic analysis.Choose all that apply.
African American or Black
Central American
South American
South Asian
East Asian
Middle Eastern
SouthEast Asian
Indigenous or First Nations
Eastern European White
Western European White
14
Do you have a history of alcohol or illicit drug abuse, known drug dependence, or are seeking or have sought treatment for alcohol or substance abuse related disorders within the past 12 months?
YESNO
15
Do you regularly drink alcohol?
YESNO
16
On average how many alcoholic drinks do you consume per week?
1-2 drinks
3-4 drinks
5-7 drinks
7-10 drinks
10-14 drinks
14+ drinks
17
Do you use tobacco or nicotine products? (e.g., cigarettes, vapes, e-cigarettes)
I currently smoke
No, I no longer smoke
I have never smoked
18
Do you use Cannabis products?
YESNO
19
Reason for using Cannabis:
Prescribed by Health Care Provider
Recreational Use
20
How often do you use cannabis?
Daily or 5-7x per week
Regularly or 3-4x per week
Weekly or 1-3x per week
Monthly or 1-3x per month
Occasionally or less than once per month
21
What type of cannabis do you use?Please choose all that apply.
Edibles
Smoking
Vaping
Topical
Other
22
Will you be able to refrain from consuming cannabis for 3 days before you visit to clinic?
YESNO
23
Have you been diagnosed with any of the following medical conditions?
Type 1 or Type 2 Diabetes
Thyroid-Related Disorder
Chronic Kidney or Liver Disease
High Cholesterol
High Blood Pressure
Current History of Gastrointestinal Issues ( e.g., IBS, Crohn's, Ulcerative Colitis, IBD)
History of Cardiovascular Disease or Cardiac Event
History of Psychiatric Condition (e.g., Depression, Anxiety, Bipolar, Schizophrenia, Psychosis etc.)
Metabolic Disease (PCOS, Metabolic Syndrome e.g.)
Chronic Inflammatory Disease (e.g., Graves, Hashimoto's, Lupus, COPD, Psoriasis, Rheumatoid Arthritis)
Immune-Compromised/Autoimmune Diseases
HIV, HepB or Hep C Positive
Other
24
If other, please indicate your medical condition
25
Is your medical condition currently in stable condition (have been treated for at least 3 months with no changes in medications), that is, you are being followed by a physician and taking prescribed medication to control their condition?
YESNO
26
Have you had/been diagnosed with cancer in the past 5 years?
YESNO
27
Was it skin cancer (basal cell carcinoma)?
YESNO
28
Are you currently receiving chemotherapy or radiation therapy?
YESNO
29
Have you had a major surgery in the past 3 months or plan to have surgery in the next 3 months?
YESNO
30
Are you lactose intolerant or have a sensitivity to dairy?
YESNO
31
Please use this Chart To Answer Next Questions(Which type are most of your poops?)
32
Looking at the diagram: Which type are most your poops?
Type 1
Type 2
Type 1 & Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
33
What percentage of your poops are between 5-6?
Less than 10%
11-30%
31-50%
51-75%
>75%
34
Have you suffered diarrhea (3 or more bowel movements per day 6-7 on the Bristol stool chart) at any time over the last 2 weeks?
YESNO
35
Have you experienced any rectal bleeding in the last 3 months?
YESNO
36
Have you bowel habits worsened over the past 3 months?
YESNO
37
Please indicate which, if any, of the following prescription medications you take:
Antibiotics (over the last 2 months)
Antidepressants
Other
38
Please list your other medications:
39
How long have you been on this prescribed medication(s)?
40
Do you use any of the following over-the-counter medications or supplements?
Prebiotics, Probiotics and Postbiotics
Dietary or Fibre-Rich Supplements
Anti-diarrheal
Anti-constipation (e.g. stool softeners, osmotic and stimulant laxatives)
Yoghurt
41
How long have you been taking them?
Less than 30 days
1-2 months
3-6 months
>6 months
42
Have you been part of a research study before?
YESNO
43
When was the last time you completed (are no longer taking products or being observed for research results) a research study?
1 month ago
3-6 months ago
More then 6 months ago
Type option 4
44
Are you planning any upcoming holiday plans or trips that may alter your regular dietary patterns?
YESNO
45
How did you hear about this study?Please tick all that apply
Facebook
Instagram
Email
Website
Radio
Google
Flyers
Reddit
YouTube
TikTok
Someone Referred Me
Other
46
Please describe where you heard about that study.
47
Why did you decide to apply for participation in this study?
Interest in the topic being studied
Compensation being offered for participation
Have participated in clinical trial before.
Other
48
What was the other reason you decided to apply?
49
I consent to receiving communications from KGK Science Inc. and their third-party service providers (via electronic mail, electronic message, telecommunication, and automatic dialing-announcing device including the use of pre-recorded or synthesized voice messages). Your information will not be shared with and/or sold to external companies and is only used for communications with KGK Science.
YESNO
Should be Empty: